Reconstruction of the tongue can be achieved by means of various local, regional, and microvascular free flaps. Local flaps commonly used for tongue reconstruction include the nasolabial flap, submental flap, infrahyoid flap, and pedicled facial artery musculomucosal (FAMM) flap. The purpose of this article is to propose a technical modification to the FAMM flap for the reconstruction of small to medium-sized tongue defects post tumour excision: islanding the flap and tunnelling it from the lingual aspect of the mandible in a single-stage procedure. Islanding of the FAMM flap was found to be an extremely useful modification, giving excellent range of movement for the flap and eliminating the need for revision in a second stage procedure.
The reconstruction of a mobile vital organ like the tongue is always a challenge. Over the years many techniques have been advocated for this purpose, from primary closure to local, regional, and free flaps. Replacing an adequate amount and ensuring pliability of the tissues used to reconstruct the tongue matters to the overall success.
Local flaps, such as the facial artery musculomucosal (FAMM) flap, which was first described by Pribaz et al. in 1992, have been used for the reconstruction of various subsites of the oral cavity. Reconstruction with the FAMM flap has traditionally been described as a two-stage procedure. A technical modification to this flap by islanding it on the facial vessels and tunnelling it on the lingual side of the mandible for the reconstruction of lateral tongue defects is presented herein. Advantages of this technique are that flap harvest is easy, the flap is an excellent colour match, it can be done in a single-stage procedure, it allows the normal range of tongue movements, there is minimal donor site morbidity, and good mouth opening is achieved.
Anatomy of the FAMM flap
Anatomically, the buccal mucosa consists of mucosa, buccinator muscle, and subcutaneous tissue, which bears the facial artery and facial vein and laterally the outer skin. The buccinator muscle is ‘c’-shaped and arises from the upper alveolus and lower alveolus; it merges with the fibres of the orbicularis oris muscle anteriorly and the pterygomandibular raphe posteriorly. The facial artery branch of the external carotid artery enters the face at the antero-inferior end of the masseter muscle and has a tortuous course. Along its course it gives off the superior labial artery, inferior labial artery, and small branches to the buccinator muscle, and eventually terminates at the medial commissure of the eye, anastomosing with the terminal branches of the ophthalmic artery. The facial vein has a relatively straighter course, lying anterior to the facial artery and eventually terminating at the internal jugular vein.
Informed consent was obtained from the patient preoperatively. A per oral excision of the tumour (squamous cell carcinoma) on the left lateral border of the tongue was done with adequate margins and the size of the defect was noted. A selective neck dissection (level I–IV) was accomplished through a single horizontal neck crease incision. The adjacent healthy buccal mucosa with no clinical/radiological evidence of abnormality was selected and a flap outlined. The 5 × 3-cm flap was marked, preserving the opening of the parotid duct superiorly. The mucosal incision was deepened through the buccinator muscle. Careful dissection was continued, leading to the location of the facial vessels. Once identified, the facial artery and vein were ligated above the superior margin of the flap. Care was taken to prevent any button hole in the lateral skin flap. Posteriorly, as the buccinator was separated at the masseter interface, the buccal fat pad was noted. Inferiorly, the flap was separated from the lower lateral aspect of the alveolar margins of the teeth. The facial vessels and marginal mandibular nerve were identified at the lower border of the mandible and preserved. Through intraoral dissection along the facial pedicle, the intraoral flap part was connected to the extraoral part. The mobilized flap was then taken below the marginal mandibular nerve completely pedicled on the facial vessels, as shown in Fig. 1 . The flap was tunnelled lingually to reconstruct the lateral tongue defect, as shown in Fig. 2 . The buccal mucosa defect was covered with the harvested buccal fat pad, as shown in Fig. 3 . The final flap inset is shown in Fig. 4 . Excellent oral care was maintained postoperatively, and mouth opening exercises were started on day 7 postoperative. The postoperative phase was uneventful. Nasogastric tube feeding was continued for 10 days postoperatively to allow the buccal fat to heal.